- Email: [email protected]
SOUTH DEVON AND EAST CORNWALL HOSPITAL, PLYMOUTH.
143
fringe
which could be
conveniently made
to cover over the
the
perineum,
and
repairs
the
vagina and perineum in
bowel when the suturing had been completed. The edges of it by deep sutures. For the following notes and area of the rupture were purified, and then the rent indebted to Mr. W. Gi<" Nash, house surgeon.
sutured up with eight Lembert sutures of fine ailk, so that the line of sutures ran somewhat obliquely along the Jength of the bowel. A second row of five sutures was added, to ensure perfect coaptation and closure; and, aastly, the fringe of omentum above-mentioned was sutured, so that it quite covered over the part of the colon just operated upon. A laceration of the peritoneum was closed by three sutures. The peritoneal cavity was carefully irrigated with warm boracic solution and then sponged clean and dry. The parietal wound was closed and dressed in the usual manner. The spray was not used. The operation lasted one hour and a half. The patient was very ill during this time, and required first a hypodermic injection of brandy and then of ether. He was cyanotic and his breathing was gasping. Soon after lie had been put back in bed another injection of brandy was required. an enema of brandy was given, but, in spite of all attempts to revive him, he sank at 6.20 P.M., or about nine hours after operation. At the necropsy a few ounces of blood-stained fluid were found in the peritoneal cavity. No other intestinal lesion was discovered. The portion of injured and sutured bowel was removed, and the suturing tested by injections of water and air. It bore both tests, and " resisted a much greater pressure than it would ever be subjected to in life." The exhibited slight subcapsular haemorrhage on the upper surface near its free edge. There was slight subperitoneal bleeding around the upper end of the left kidney. The lungs were intensely congested and cedematous, especially on their upper lobes. This was probably the result of long ansesthetisation. Remarks -Had this young man been in an ordinary condition of health, Mr. Croft believes that he would have The lesion on the intestine had made a good recovery. been effectually closed, and the peritoneal cavity had so far as the eye could see been sufficiently purified. The cold and starvation which the poor fellow had suffered during the preceding week had rendered him incapable of combating such a sequence of events as shock, rupture of intestine, peritonitis, and the long operation with aneesthesia. The two cases of Mr. Croft’s, already reported in this journal, were pointed to by him as indicating the propriety of early exploratory operation in similar injuries to the abdomen. This case particularly emphasises the value of the measure. A surgeon would have been had he made an exploratory incision on the admisjustified, sion of the patient into the hospital. As the lesion had oc. curred to the large intestine, feeding by the mouth might have been commenced at a relatively early period-indeed, at once. Would it have been better to have made an artificial anus in this case ? Emphatically no. The purification of the peritoneum and the suturing of the intestine to the parietal wound would have occupied nearly as long as the proceeding adopted by Mr. Croft. was
Later
liver
SOUTH DEVON AND EAST CORNWALL HOSPITAL, PLYMOUTH. MALFORMED ANUS AND LOWER BOWEL; RIGHT INGUINAL COLOTOMY; PLASTIC OPERATION ON ANUS; CURE.
(Under the
of Mr. SWAIN.) SUCH a condition as that described below as a cause of chronic obstruction of the bowels at the age of this patient is almost, if not quite, unknown, for as a rule patients the subjects of these malformations undergo operation in early infancy. Of the varieties of malformation of the rectum, as classified by most standard writers on the diseases of this region, this is an example of the sixth-namely, that in which the bowel ends in the bladder, urethra, or vagina, and the anus is absent. Of these modes of termination, that in the vagina is the most common, and Kelseyl says that in females the opening is seldom if ever into the bladder, but is sometimes into the urethra. The treatment of this case was very successful. It will be noted that the plastic operation resembles that performed by Rizzoli, who makes an incision backwards from the vaginal anus towards the coccyx, not opening the rectum, then carefully dissects out the end of the rectum and its orifice, transplants it to 1
care
Diseases of the Rectum and Anus.
front
we
are
to hospital on Nov. 20th, with a small Her mother stated that she was misplaced anus, from which a slight faecal discharge was constantly oozing. For several years she has had a swollen abdomen, and has suffered agonising pain in it. She also has frequently had feverish attacks. On admission the patient was a large, pale-faced, emaci . ated child, with a swollen abdomen. The rectum opened by a small orifice on the posterior wall of the vagina, just within the sphincter vaginae. The opening barely admitted the tip of the little and from it a facial discharge was constantly oozing. There waa a large swelling in the abdomen, extending up out of the pelvis into the hypogastrium, and thence upwards along the right side of the spine to.the right hypochondriac region, from which it passed to the left across the epigastrium to the left hypochondrium, where it ended. It was largest at its lowest part, and gradually tapered off as it ascended. It was bard, but could be indented by the fingers. There was no accumulation in the normal position of the descending colon. Castor oil was given three times a day, and bowels were considerably relieved. On several occasions before the bowel was opened the temperature ran up to 103°, 104°, or 105°. Jan. 10th, 1890.-An incision was made in the left loin as for colotomy, but the colon could not be reached. The peritoneum was opened, and the abdomen explored, but the colon could not be found. The peritoneum was stitched up again, and the wound closed. Feb. 6th.-The abdomen has become much more distended by faecal accumulation. 7th -An oblique incision was made in the right iliac region parallel to Poupart’s ligament. The peritoneal cavity was opened, and the omentum presented. The enormously distended and hypertrophied large intestine was felt extending downwards into the pelvis and upwards towards the liver. It lay rather to the right of the spine. The edges of the peritoneum were sutured to the edges of the skin; then the peritoneal and muscular coats of the bowel were sutured to the abdominal wall. The intestine
M.
J-, aged six, wu..-. ,1 imitted
1889.
born
finger,
the
was
not
opened.
15th.-The bowel was opened and the stitches removed. After this for weeks there was an enormous evacuation of faecal matter. The faeces were washed out daily from the colotomy wound by a catheter passed through the anal aperture. Much of the faecal matter wa3 so hard that it had to be removed under anaesthetics by scoop and fingers. The catheter could be passed in at the anal aperture, and out through the colotomy wound, four inches from entrance to exit. April 10th.-She was sent to the convalescent home for change of air to pick up strength for further operation. She was readmitted on April 30th very much improved in health by her stay at the Saltash Convalescent Home. There was a large, hard faecal accumulation below the inguinal opening, which showed a tendency to close. May 8th.-Methylene was given and the faecal mass broken down by the fingers introduced one at the groin and the other at the anus. llth -Since the bowel was cleared out the child has had an attack of peritonitis.
13th.-Rapidly improving. 24th.-Methylene was given, and the rectum dissected off the posterior vaginal wall for over two inches. An incision was made in the perineum from the back of the vagina to near
the coccyx. The
anus was
then stitched
as
far back
as
possible, and a new perineum made between the anus and the vagina. Considerable traction was required to drag the rectum down to the level of the skin of the perineum. June 3rd.-There is fair union of the opposing surfaces of the new perineum. 20th.-The index finger is passed daily into the anus. July lst.-The bowels act partly through the anus. The motions are kept loose by castor oil, and the lower bowel is washed out daily by introducing the irrigating tube at the anus or the colotomy opening. 22nd.--The inguinal wound is a mere pinhole. The faeces are passed by the natural way with the help of a daily enema.
2nd.-Child discharged. Oct. 15th.-The child has grown quite strong and fat. Her mother says that the bowels act nearly every day,
Aug.
144 and only occasionally require opening medicine or injec- another day. On the afternoon of Thursday, the Bfcb tions. She has complete control, except after a dose of day of anuria, the patient became drowsy and weaker, se, castor oil, when there is slight staining of the diaper. that it was difiicult to rouse her to obtains answers to There is no discharge from the vagina, and no trouble questions. Her pulse was weak, her temperature 99°, and with micturition. There is no collection of faeces felt on she had become less sensitive to pain, and indifferent to what palpating the abdomen. The inguinal colotomy wound is was passing around. Ether was given, and Mr. Lucas cut quite healed, and at its site there is a little tendency to down on her remaining kidney and discovered a conical hernia. The index finger passes easily into the rectum. stone acting as a ball-valve to the top of the ureter. The, Just inside the vaginal orifice is a small fistulous opening stone was rather more than three-quarters of an inch in into the rectum. There is a small perineum between the and from three-eighths to five-eighths in diameter. Urine began to drop away out of the wound as soon as the vagina and the anus. pelvis of the kidney was opened, but the pelvis was not found much dilated. The patient recovered well from the anaesthetic, and was sick once only after the operation. For twelve days all urine was passed by the wound in the loin. Then an ounce and a half was passed with great pain from the bladder, and the quantity gradually increased. ROYAL MEDICAL & CHIRURGICAL SOCIETY. After the nineteenth day all the urine was passed naturally. The wound ran an aseptic course, and the patient’s teni. rose above normal. Healing was complete perature Total Nephro-lithotomy for Suppression of Urine. - ten weeksscarcely after the operation. During the last five years Hcemorrhage after Nephro-lithotomy. she has been employed in household duties, and has enjoyed AN ordinary meeting of this Society was held on Jan. 13th, good health. The patient was exhibited, together with her the President, Mr. Timothy Holmes, in the chair. right kidney, which was excised, and the stone removed Mr. CLEMENT LUCAS read a paper on a case of Nephro- from the left kidney for total suppression of urine. lithotomy (following nephrectomy) for Total Suppression of ’ Mr. RICKMAN J. GODLEE relatedacase of Removal of Large Urine lasting five days, with complete recovery and good Calculi, first from one kidney and afterwards from the other, health five years after the operation. This case was men- in which death occurred from haemorrhage after the second tioned by the editors of the medical journals at the date of operation. The patient was a gentleman aged thirty-seven, the operation, in 1885, as a case of exceptional interest, but who first complained of renal symptoms in 1886. In the the details of the case have never been before published, autumn of 1888 a diagnosis of left renal calculus and left nor has the patient, or her kidney, or the stone which caused pyelitis was made, but mischief on the right side was suppression, ever been exhibited before. The author had de- suspected also. In November, 1888, a large quantity of layed publishing it because those to whom he mentioned it, stone-uric acid and phosphatic-was removed from the whilst applauding the attempt to save a life on the extreme left kidney. The patient made a rapid recovery, but the verge of dissolution, threw the coldest doubt upon the closure of the wound was not permanent, and after several patient’s future, maintaining that even if she recovered from febrile attacks it was found best for the patient to wear a the immediate effects her life must be a short and painful plug permanently in the fistula, to prevent periodical one ; that the one remaining kidney, having been opened accumulations of pus and urine in the kidney. At one time and drained, would rapidly degenerate, or another stone the ureter became completely blocked, and an operation would quickly form and bring about a final catastrophe. was undertaken to remove a stone which was supposed t(> After the lapse of five years the author thought he might be obstructing it. Bone was found, but the ureter became be acquitted of any attempt to claim an incomplete success. again patent after the operation, and the state of the The patient was still living and enjoying the best of health, kidney very much improved. The patient now became and a freedom from pain, discomfort, and baematuria, which, convinced that he had stone in the right kidney. The riskw for seventeen years before her right kidney was removed, of an operation were explained, but he was recommended to were almost constantly present. The operation for total submit to it, and on Nov. 19th, 1890, large masses of uric suppression of urine was one that the author had long con- acid stone were removed. No bleeding followed the sidered justifiable, and he had on more than one occasion first incision into the kidney, but the laceration that was previously publicly advocated its performance. The patient caused by the removal of the stones gave rise to very free had been under the care of Mr. F. D. Atkins of Sutton, venous hemorrhage, which was easily controlled by presSurrey, to whom much credit was due, both for the original sure. At the completion of the operation there was little diagnosis and for the promptitude with which he acted or no bleeding, but it was thought safer to plug the pelvis when total suppression occurred. F. F-, aged thirty- of the kidney. The patient remained in fair condition for seven, was first admitted into Guy’s Hospital on June 22nd, an hour and a half after the operation, and then suddenly 1885. There was a strong family history of consumption. died, as the result of fresh haemorrhage from the kidney. For seventeen years she had suffered from haematuria at The rarity of the accident was dwelt upon, and attempts intervals, and for nine or ten years this had been accom- were made to suggest means of combating it if it arose. Mr. GODLEE read a letter from Mr. Mayo Robson of panied with pain on the right side of the abdomen, and for seven years a tumour diagnosed as a floating kidney had Leeds, mentioning that, in a case of nephro-lithotomy which been felt on this side. On July 14th the right kidney was he had operated upon three years ago, he had made a small removed by lumbar incision. It was a mere shell containing incision into the renal substance, which was followed by masses of stone, and weighing 21 oz. The wound healed comviolent haemorrhage. This, for a time, he was unable to, pletely, and she left the hospital convalescent on Aug. 10th, restrain by ordinary means, and finally he had to excise the just within a month of the operation. All went well for patient’s kidney in order to save his life. The source of the three months. She had returned to her household duties, haemorrhage was an abnormal vein in the capsule, whichI was free from pain and haematuria, and much satisfied with had been wounded. He said that he knew of another case the result of the operation. On Sunday morning, Oct. 24th, in which violent haemorrhage had followed the same opera1885, she was suddenly seized, between seven and eight tion. As it appeared to cease, however, the wound was o’clock, with most violent and agonising pain in her back closed in the usual way, but it recurred the next day, and and left loin. The pain passed through the loin to the front in this case, too, it had become necessary to excise the of the abdomen and groin. About eight o’clock she passed kidney, but with a fatal result. a little urine, but from that time all secretion stopped. Mr. ARBUTHNOT LANE mentioned a case in which there Vomiting commenced about half-past eight on the had been severe hemorrhage after an incision into the same morning, and was continued at intervals and whenkidney which he had been enabled to control by sutures ever anything was taken. Mr. Atkins was called to see passed through the kidney substance. Dr. G. HARLEY congratulated Mr. Lucas upon the brilher and found the bladder empty. Vomiting and anuria continued throughout Sunday, Monday, and Tuesday. On liant result which he had obtained. In doing so, however, Tuesday Mr. Lucas met Mr. Atkins in consultation, and he was bound to state that it reflected upon medicine, for if The symptoms continued without physicians had diagnosed and treated the case in proper advised operation. cessation on Wednesday, when she was brought to London, time, there would be none of these calculi for surgeons to but Mr. Lucas’s medical colleagues still advised him to remove. The difficulty lay in the diagnosis. When renal postpone operation till a further trial had been given to calculi were small, and there was no beriaorrhage and very diuretics, and in deference to their opinion he waited little pus, the cases were very apt and very frequently were
length
Medical Societies.
I
fringe
which could be
conveniently made
to cover over the
the
perineum,
and
repairs
the
vagina and perineum in
bowel when the suturing had been completed. The edges of it by deep sutures. For the following notes and area of the rupture were purified, and then the rent indebted to Mr. W. Gi<" Nash, house surgeon.
sutured up with eight Lembert sutures of fine ailk, so that the line of sutures ran somewhat obliquely along the Jength of the bowel. A second row of five sutures was added, to ensure perfect coaptation and closure; and, aastly, the fringe of omentum above-mentioned was sutured, so that it quite covered over the part of the colon just operated upon. A laceration of the peritoneum was closed by three sutures. The peritoneal cavity was carefully irrigated with warm boracic solution and then sponged clean and dry. The parietal wound was closed and dressed in the usual manner. The spray was not used. The operation lasted one hour and a half. The patient was very ill during this time, and required first a hypodermic injection of brandy and then of ether. He was cyanotic and his breathing was gasping. Soon after lie had been put back in bed another injection of brandy was required. an enema of brandy was given, but, in spite of all attempts to revive him, he sank at 6.20 P.M., or about nine hours after operation. At the necropsy a few ounces of blood-stained fluid were found in the peritoneal cavity. No other intestinal lesion was discovered. The portion of injured and sutured bowel was removed, and the suturing tested by injections of water and air. It bore both tests, and " resisted a much greater pressure than it would ever be subjected to in life." The exhibited slight subcapsular haemorrhage on the upper surface near its free edge. There was slight subperitoneal bleeding around the upper end of the left kidney. The lungs were intensely congested and cedematous, especially on their upper lobes. This was probably the result of long ansesthetisation. Remarks -Had this young man been in an ordinary condition of health, Mr. Croft believes that he would have The lesion on the intestine had made a good recovery. been effectually closed, and the peritoneal cavity had so far as the eye could see been sufficiently purified. The cold and starvation which the poor fellow had suffered during the preceding week had rendered him incapable of combating such a sequence of events as shock, rupture of intestine, peritonitis, and the long operation with aneesthesia. The two cases of Mr. Croft’s, already reported in this journal, were pointed to by him as indicating the propriety of early exploratory operation in similar injuries to the abdomen. This case particularly emphasises the value of the measure. A surgeon would have been had he made an exploratory incision on the admisjustified, sion of the patient into the hospital. As the lesion had oc. curred to the large intestine, feeding by the mouth might have been commenced at a relatively early period-indeed, at once. Would it have been better to have made an artificial anus in this case ? Emphatically no. The purification of the peritoneum and the suturing of the intestine to the parietal wound would have occupied nearly as long as the proceeding adopted by Mr. Croft. was
Later
liver
SOUTH DEVON AND EAST CORNWALL HOSPITAL, PLYMOUTH. MALFORMED ANUS AND LOWER BOWEL; RIGHT INGUINAL COLOTOMY; PLASTIC OPERATION ON ANUS; CURE.
(Under the
of Mr. SWAIN.) SUCH a condition as that described below as a cause of chronic obstruction of the bowels at the age of this patient is almost, if not quite, unknown, for as a rule patients the subjects of these malformations undergo operation in early infancy. Of the varieties of malformation of the rectum, as classified by most standard writers on the diseases of this region, this is an example of the sixth-namely, that in which the bowel ends in the bladder, urethra, or vagina, and the anus is absent. Of these modes of termination, that in the vagina is the most common, and Kelseyl says that in females the opening is seldom if ever into the bladder, but is sometimes into the urethra. The treatment of this case was very successful. It will be noted that the plastic operation resembles that performed by Rizzoli, who makes an incision backwards from the vaginal anus towards the coccyx, not opening the rectum, then carefully dissects out the end of the rectum and its orifice, transplants it to 1
care
Diseases of the Rectum and Anus.
front
we
are
to hospital on Nov. 20th, with a small Her mother stated that she was misplaced anus, from which a slight faecal discharge was constantly oozing. For several years she has had a swollen abdomen, and has suffered agonising pain in it. She also has frequently had feverish attacks. On admission the patient was a large, pale-faced, emaci . ated child, with a swollen abdomen. The rectum opened by a small orifice on the posterior wall of the vagina, just within the sphincter vaginae. The opening barely admitted the tip of the little and from it a facial discharge was constantly oozing. There waa a large swelling in the abdomen, extending up out of the pelvis into the hypogastrium, and thence upwards along the right side of the spine to.the right hypochondriac region, from which it passed to the left across the epigastrium to the left hypochondrium, where it ended. It was largest at its lowest part, and gradually tapered off as it ascended. It was bard, but could be indented by the fingers. There was no accumulation in the normal position of the descending colon. Castor oil was given three times a day, and bowels were considerably relieved. On several occasions before the bowel was opened the temperature ran up to 103°, 104°, or 105°. Jan. 10th, 1890.-An incision was made in the left loin as for colotomy, but the colon could not be reached. The peritoneum was opened, and the abdomen explored, but the colon could not be found. The peritoneum was stitched up again, and the wound closed. Feb. 6th.-The abdomen has become much more distended by faecal accumulation. 7th -An oblique incision was made in the right iliac region parallel to Poupart’s ligament. The peritoneal cavity was opened, and the omentum presented. The enormously distended and hypertrophied large intestine was felt extending downwards into the pelvis and upwards towards the liver. It lay rather to the right of the spine. The edges of the peritoneum were sutured to the edges of the skin; then the peritoneal and muscular coats of the bowel were sutured to the abdominal wall. The intestine
M.
J-, aged six, wu..-. ,1 imitted
1889.
born
finger,
the
was
not
opened.
15th.-The bowel was opened and the stitches removed. After this for weeks there was an enormous evacuation of faecal matter. The faeces were washed out daily from the colotomy wound by a catheter passed through the anal aperture. Much of the faecal matter wa3 so hard that it had to be removed under anaesthetics by scoop and fingers. The catheter could be passed in at the anal aperture, and out through the colotomy wound, four inches from entrance to exit. April 10th.-She was sent to the convalescent home for change of air to pick up strength for further operation. She was readmitted on April 30th very much improved in health by her stay at the Saltash Convalescent Home. There was a large, hard faecal accumulation below the inguinal opening, which showed a tendency to close. May 8th.-Methylene was given and the faecal mass broken down by the fingers introduced one at the groin and the other at the anus. llth -Since the bowel was cleared out the child has had an attack of peritonitis.
13th.-Rapidly improving. 24th.-Methylene was given, and the rectum dissected off the posterior vaginal wall for over two inches. An incision was made in the perineum from the back of the vagina to near
the coccyx. The
anus was
then stitched
as
far back
as
possible, and a new perineum made between the anus and the vagina. Considerable traction was required to drag the rectum down to the level of the skin of the perineum. June 3rd.-There is fair union of the opposing surfaces of the new perineum. 20th.-The index finger is passed daily into the anus. July lst.-The bowels act partly through the anus. The motions are kept loose by castor oil, and the lower bowel is washed out daily by introducing the irrigating tube at the anus or the colotomy opening. 22nd.--The inguinal wound is a mere pinhole. The faeces are passed by the natural way with the help of a daily enema.
2nd.-Child discharged. Oct. 15th.-The child has grown quite strong and fat. Her mother says that the bowels act nearly every day,
Aug.
144 and only occasionally require opening medicine or injec- another day. On the afternoon of Thursday, the Bfcb tions. She has complete control, except after a dose of day of anuria, the patient became drowsy and weaker, se, castor oil, when there is slight staining of the diaper. that it was difiicult to rouse her to obtains answers to There is no discharge from the vagina, and no trouble questions. Her pulse was weak, her temperature 99°, and with micturition. There is no collection of faeces felt on she had become less sensitive to pain, and indifferent to what palpating the abdomen. The inguinal colotomy wound is was passing around. Ether was given, and Mr. Lucas cut quite healed, and at its site there is a little tendency to down on her remaining kidney and discovered a conical hernia. The index finger passes easily into the rectum. stone acting as a ball-valve to the top of the ureter. The, Just inside the vaginal orifice is a small fistulous opening stone was rather more than three-quarters of an inch in into the rectum. There is a small perineum between the and from three-eighths to five-eighths in diameter. Urine began to drop away out of the wound as soon as the vagina and the anus. pelvis of the kidney was opened, but the pelvis was not found much dilated. The patient recovered well from the anaesthetic, and was sick once only after the operation. For twelve days all urine was passed by the wound in the loin. Then an ounce and a half was passed with great pain from the bladder, and the quantity gradually increased. ROYAL MEDICAL & CHIRURGICAL SOCIETY. After the nineteenth day all the urine was passed naturally. The wound ran an aseptic course, and the patient’s teni. rose above normal. Healing was complete perature Total Nephro-lithotomy for Suppression of Urine. - ten weeksscarcely after the operation. During the last five years Hcemorrhage after Nephro-lithotomy. she has been employed in household duties, and has enjoyed AN ordinary meeting of this Society was held on Jan. 13th, good health. The patient was exhibited, together with her the President, Mr. Timothy Holmes, in the chair. right kidney, which was excised, and the stone removed Mr. CLEMENT LUCAS read a paper on a case of Nephro- from the left kidney for total suppression of urine. lithotomy (following nephrectomy) for Total Suppression of ’ Mr. RICKMAN J. GODLEE relatedacase of Removal of Large Urine lasting five days, with complete recovery and good Calculi, first from one kidney and afterwards from the other, health five years after the operation. This case was men- in which death occurred from haemorrhage after the second tioned by the editors of the medical journals at the date of operation. The patient was a gentleman aged thirty-seven, the operation, in 1885, as a case of exceptional interest, but who first complained of renal symptoms in 1886. In the the details of the case have never been before published, autumn of 1888 a diagnosis of left renal calculus and left nor has the patient, or her kidney, or the stone which caused pyelitis was made, but mischief on the right side was suppression, ever been exhibited before. The author had de- suspected also. In November, 1888, a large quantity of layed publishing it because those to whom he mentioned it, stone-uric acid and phosphatic-was removed from the whilst applauding the attempt to save a life on the extreme left kidney. The patient made a rapid recovery, but the verge of dissolution, threw the coldest doubt upon the closure of the wound was not permanent, and after several patient’s future, maintaining that even if she recovered from febrile attacks it was found best for the patient to wear a the immediate effects her life must be a short and painful plug permanently in the fistula, to prevent periodical one ; that the one remaining kidney, having been opened accumulations of pus and urine in the kidney. At one time and drained, would rapidly degenerate, or another stone the ureter became completely blocked, and an operation would quickly form and bring about a final catastrophe. was undertaken to remove a stone which was supposed t(> After the lapse of five years the author thought he might be obstructing it. Bone was found, but the ureter became be acquitted of any attempt to claim an incomplete success. again patent after the operation, and the state of the The patient was still living and enjoying the best of health, kidney very much improved. The patient now became and a freedom from pain, discomfort, and baematuria, which, convinced that he had stone in the right kidney. The riskw for seventeen years before her right kidney was removed, of an operation were explained, but he was recommended to were almost constantly present. The operation for total submit to it, and on Nov. 19th, 1890, large masses of uric suppression of urine was one that the author had long con- acid stone were removed. No bleeding followed the sidered justifiable, and he had on more than one occasion first incision into the kidney, but the laceration that was previously publicly advocated its performance. The patient caused by the removal of the stones gave rise to very free had been under the care of Mr. F. D. Atkins of Sutton, venous hemorrhage, which was easily controlled by presSurrey, to whom much credit was due, both for the original sure. At the completion of the operation there was little diagnosis and for the promptitude with which he acted or no bleeding, but it was thought safer to plug the pelvis when total suppression occurred. F. F-, aged thirty- of the kidney. The patient remained in fair condition for seven, was first admitted into Guy’s Hospital on June 22nd, an hour and a half after the operation, and then suddenly 1885. There was a strong family history of consumption. died, as the result of fresh haemorrhage from the kidney. For seventeen years she had suffered from haematuria at The rarity of the accident was dwelt upon, and attempts intervals, and for nine or ten years this had been accom- were made to suggest means of combating it if it arose. Mr. GODLEE read a letter from Mr. Mayo Robson of panied with pain on the right side of the abdomen, and for seven years a tumour diagnosed as a floating kidney had Leeds, mentioning that, in a case of nephro-lithotomy which been felt on this side. On July 14th the right kidney was he had operated upon three years ago, he had made a small removed by lumbar incision. It was a mere shell containing incision into the renal substance, which was followed by masses of stone, and weighing 21 oz. The wound healed comviolent haemorrhage. This, for a time, he was unable to, pletely, and she left the hospital convalescent on Aug. 10th, restrain by ordinary means, and finally he had to excise the just within a month of the operation. All went well for patient’s kidney in order to save his life. The source of the three months. She had returned to her household duties, haemorrhage was an abnormal vein in the capsule, whichI was free from pain and haematuria, and much satisfied with had been wounded. He said that he knew of another case the result of the operation. On Sunday morning, Oct. 24th, in which violent haemorrhage had followed the same opera1885, she was suddenly seized, between seven and eight tion. As it appeared to cease, however, the wound was o’clock, with most violent and agonising pain in her back closed in the usual way, but it recurred the next day, and and left loin. The pain passed through the loin to the front in this case, too, it had become necessary to excise the of the abdomen and groin. About eight o’clock she passed kidney, but with a fatal result. a little urine, but from that time all secretion stopped. Mr. ARBUTHNOT LANE mentioned a case in which there Vomiting commenced about half-past eight on the had been severe hemorrhage after an incision into the same morning, and was continued at intervals and whenkidney which he had been enabled to control by sutures ever anything was taken. Mr. Atkins was called to see passed through the kidney substance. Dr. G. HARLEY congratulated Mr. Lucas upon the brilher and found the bladder empty. Vomiting and anuria continued throughout Sunday, Monday, and Tuesday. On liant result which he had obtained. In doing so, however, Tuesday Mr. Lucas met Mr. Atkins in consultation, and he was bound to state that it reflected upon medicine, for if The symptoms continued without physicians had diagnosed and treated the case in proper advised operation. cessation on Wednesday, when she was brought to London, time, there would be none of these calculi for surgeons to but Mr. Lucas’s medical colleagues still advised him to remove. The difficulty lay in the diagnosis. When renal postpone operation till a further trial had been given to calculi were small, and there was no beriaorrhage and very diuretics, and in deference to their opinion he waited little pus, the cases were very apt and very frequently were
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